|
The First Death
Mary Claire O'Brien, MD
Medical school curricula are more humanistic these days, but when we went to school I don't remember there being much emphasis on how to encounter death. We saw patients who were sick enough to die, and many of us had someone die while we were students on our clinical rotations. But being a student is one thing. There is something different about being The Doctor for someone who is dying, if only the intern...something Responsible and Wise that is supposed to be within our purview. I had never seen anyone die before that hot July night at West Park Hospital, when I was the on-call intern for the Step-Down Unit, and Mr. Randolph passed away.
West Park Hospital was a tiny suburban facility along with Main Line in Philadelphia. I hear a larger hospital has since bought it out and, because it was tiny, they made it into a rehab center. Back in 1985, "The Park" was where we neophytes received our baptism of fire. Eight ICU beds, four CCU beds, and a 20-bed Step-Down Unit, under the supervision of attending physicians from Medicine, Cardiology, Surgery, and Emergency Medicine. It was every third night on-call overnight, just an intern and a supervisory resident. The patients were mostly well-to-do, but we had some poor people too, from the section of West Philly that borders the Main Line.
We interns would sit in the cafeteria taking sign out and fortifying ourselves for the night ahead: lasagna, rice pudding, Tastykakes. The interns going off duty would present their patients to the intern on-call, pass along the "To Do" lists, and get the heck out of there before those damn beepers went off again. My friend Kim signed out the usuals: partial thromboplastin times to be checked for patients on heparin drips, some cardiac enzymes for a patient with a suspected acute MI. Nothing to worry about. Our teammate Dominic had a short list too: a 60-year old man with metastatic lung cancer, expected to die at any moment, in the hospital for oxygen and comfort care. "No money and no family," said Dom. The attending physician had put Mr. Randolph in a room right across from the nurses' station, so that he could be watched. "He's DNR" Dom assured me, "but I'm not sure he knows how bad it is." What a sign out! There was no such thing as hospice.
I made the rounds after dinner, peeking my head behind the curtains in the Unit, checking with the charge nurses, wandering...it was a quiet night. The monitors purred low and steady as the night nurses sorted through the order racks, and the unit secretary filled out the next day's X-ray requests. "Mr. Randolph is having ectopy," said someone. I looked up. Number 214. Sinus rhythm, but with frequent premature ventricular contractions.
"He's DNR, right?" I asked, reaching for the chart. "Who's his nurse?"
"Me," said Nancy. "I had him last night too. Yeah, he's DNR." She fiddled with a rebellious strand of hair that had escaped from the ponytail at the nape of her neck. "He seems restless," she said tentatively. I sighed, and read the last attending note. "Patient intermittently awake, without complaint. Exam unchanged. Condition terminal. No further intervention. Continue comfort measures."
"I tried to sit him up better, and suction him," said Nancy. "I don't know. He just seems restless." She hesitated, looking down at her heavy white shoes, unable to be more specific. There was nothing medically to be done, and we both knew it. Still, a doctor learns early on to pay attention to good nurses.
"It's OK," I said. "I'll check him."
Mr. Randolph lay in the far bed, next to the windows. He was a tall man, from what I could see of his shape under the bedcovers. The skin of his face was thin and grey, drawn tight like tissue paper over his bones. There were deep hollows under his eyes. Poking through the sheets was one gnarled brown hand, like a tree branch on which his cotton gown had been hung out to dry. The room smelled of urine, and something I did not recognize at the time – death.
"Mr. Randolph?" I whispered.
Nothing.
"Mr. Randolph. Can I help you?"
I touched his chest – or the gown, really. He drew irregular breaths, labored enough to retract the slender neck muscles away from his clavicles and sternum – very, very slowly. I tried to look in his eyes, but they were empty. "He's dying!" I thought in a panic. "Mr. Randolph!" I sat down. What do I tell him? What should I do? What should I say? Tell the truth, I fell back on.
"You're dying, Mr. Randolph," I said.
I might have said, "It's Thursday." I wanted to tell the truth. I had tried to be gentle. "You're dying now, Mr. Randolph."
 But Mr. Randolph was too tired to recognize a stranger, doctor or otherwise. He was on a train, pulling out of the station, and some idiot in a white coat was waving a flag, announcing the railway schedule. He leaned back, and turned away. There was a loud gasp, as he struggled for air. I knew I had failed. I adjusted his oxygen mask, and left the room.
Back at the nurses' station, someone had just told a joke, and they were all laughing, except Nancy. She looked very concerned. "It's almost over," I told her. The monitor for 214 was now very bizarre – wide complexes, then a long pause, then a few more beats, then nothing. It was flat.
"Get a strip for the chart," I mumbled. "I'll be back later to do the paperwork."
I knew how to be a Doctor. It would be a long time before I learned how to be a Nurse. |